MEDICARE: JENNAH LOUISE HICKLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1972196640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNAH LOUISE HICKLE

Provider Business Mailing Address
First Line	:	15425 LAS MANZANITAS RD
Second Line	:
City	:	RAMONA
State	:	CA
Zip	:	92065-7421
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15425 LAS MANZANITAS RD
Second Line	:
City	:	RAMONA
State	:	CA
Zip	:	92065-7421
Country	:	US
Telephone Number	:	760-803-2494
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2021
Last Update Date	:	02/14/2021

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Directions to “ JENNAH LOUISE HICKLE ” Practice Location

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